the appropriation subcommittee on labor, health, human services, education and

related agencies will come to order. certainly pleased, secretary azar, to have you here this morning. i'm sure we're going to have a number of questions about your budget and i preface that by saying we understand that the final congressional action and administrative -- administration action on fy-18 occurred after you were asked to submit your budgets. still, there are things we need to talk about. the actual budget i think you submitted is $1.9 billion. that's 2.1% lower than the bill we just passed. and then in addition to that, there is another $5.6 billion that shifts from the mandatory side to the discretionary side in your budget. i think when you add all this up, the budget's actually more like 16% lower than the budget

we just voted on. i'm sure we're going to talk about that and look at that. the budget request had to be submitted when it had to be submitted. but throughout the bill, looking at some of our priorities, medical research, early childhood education, education generally, the preparedness programs are programs that will be questions on. i certainly agree that we ought to look everywhere we can for savings. we should look for programs that aren't working and make that decision that this is just an idea that wasn't necessarily bad idea. it didn't work. look for programs that we can combine to where we eliminate both redund ancy and administrative costs. but at the same time, the committee will want to be heard on what we think should happen. we worked hard to craft a bill for your department this year that i think reflected the

priorities of our members, of the department itself, and the administration. we provided $3 billion increase for the national institutes of health. over the past three years, we've inkree increased nih research. that increased by 23%. we'll have dr. collins in to talk about that. i understand there is some questions from omb about the way we believe that money should be spent. and we'll be insisting on on the way we believe that money should be spent. you know, the president agreed to this budget. and management from omb is one thing, trying to decide what the congressional priorities should be from omb would be another thing. we're committed and we'll remain committed along with you to addressing the opioid epidemic.

the opioid has passed car accidents as the number one cause of accidental death in the country. that budget was increased by $2.55 billion, a 244% increase. at some point i think we want to look pretty carefully and make sure we're not increasing that budget faster than the money can reasonably be spent. a lot of that increase, a little over half of that increase, $1.5 billion, is flexible funding for the states. and i would also think that right now is a good time to let the states help us figure out what works and what doesn't work and where it works and where it may not work. it's great advantage of our system and this is a -- this is a cross-ice is that needs to be dealt with quickly but needs to be dealt with in a way that allows states to try as many

things as they think might work. i know in missouri we're doing the medication first approach combined with counseling. other states are doing that. and other states are looking at this in a different way. but that flexibility, i think, in the at least initially is going to be very important and may turn out to be very important throughout this crisis because it's a big country with lots of different issues to be addressed. i think it's important and our committee has gone on record thinking it's important to create mental -- to treat mental health just like we treat any other health problem. i think those issues are coupled with opioid dependcy,mental health efforts are clearly an important part of whether we're successful in the opioid issue. but they're also critically important as we look to overall

health. we've made a big increase in mental health funding. in the omnibus, it was $306 million, $160 million of that went to the mental health block grant and another $100 million went to new programs certified at look at targetted certified community behavioral health clinics. i'm pleased that both the medical research and funding to combat opioid -- the opioid epidemic were reflected in your budget. but i was disappointed that we didn't see as strong a commitment in your budget as we just made in our spending bill. i'm also concerned about the proposed elimination of the heating assistance program, the heating, air conditioning assistance program, the children's hospital graduate

medical education. i actually don't know where that money is supposeded to come from if it doesn't come from discretionary. i'd like to figure out a way that graduate medical education at children's hospitals has a dedicated source just like all other graduate medical education has. zeroing out would not be the way to solve that problem unless you got a better replacement and i'd like to see a permanent replacement. also, i have concerns that some of the workforce programs are not as supported in this budget as i think they will be in a product that comes out of this committee. but do you have a big job. we appreciate the job you do. i personally appreciate the great expertise you bring it to having been in the department before and having worked in this area for so long and i appreciate that. but, you know, our job is to work together to try to make

what we do better. and i'm pleased to get to work with senator murray as we do that. if you have opening comments, we'll turn to those right now. >> all right. thank you very much, chairman blunt. welcome, secretary azar. it is glad to see you back and recovered and with us to day. i'm interested to hear your testimony about the department's fiscal year 2019 budget. i have to tell you, there are a lot of things in it that concern me. while i know you are not part of this administration when they started working on this budget request, you have made it clear that you do plan to continue some of the alarming ideological approaches this administration has taken since day one. a budget isn't just to set a number. it's a statement of values and priorities and this budget seems to have been written by an administration that believes the goal of the department of health and human services is to raise family's health care costs and undermine patient's access to care. it is not. it's clear instead of fighting to make the health care system stronger, instead of

prioritizing ways to make it more affordable or accessible or effective for our families and patients, this administration is continuing to prioritize health care sabotage. it's clear instead of proposing solutions to make sure everyone can get the health care they need, regardless of the background or pre-existing conditions, this administration will continue to put in place policies that weaken protection ands put the needed health care further out of their reach. and this budget does take alarming step backwards when it comes to women's health care. continuing a much larger trend we've seen from the trump-pence administration, time after time the trump-pence approach put ideology over women's help edge and reproductive freedom. like the months of to undermine the title ten family planning program and the health care providers that offer very important services to women across the country who might not get the care they need otherwise. and then i'm very concerned about the way you've handled the teen pregnancy prevention

program terminating grants in the middle of a five-year cycle, a decision that was made with little rational and apparently at the direction of political appointees against the advice of career staff. and significantly changing the focus of that program to promote a single ideological approach, a decision which is contrary to congressional intent which is to support "programs that are proven effective through rigorous evaluation." page after page of this budget request raises new red flags. proposes to cut cdc by over $2 billion which it would devastate the agency's crucial work to promote immunizations, combatting emerging infections, preventing chronic disease and keeping our communities healthy. the budget eliminates safety net programs in critical assistance to millions of people like the program the chairman mentioned and the community services block grant which gives states resources to address the challenges of poverty.

it eliminates the block grant and programs that help families face adversity and keep their heads above water. it cuts $975 million from the health resources and services administration workforce programs which support training for every type of health care provider. it eliminates funding for preschool development grants which we authorized and funded on a bipartisan basis to provide high quality preschool to tens of thousands of families. so this is not the budgets of an administration that values fighting, keeping our communities healthy. it's not the budgets of an administration that values evidence, science, and good policy making practice. and it is actually not the direction this committee chose to take in our recent bipartisan spending bill. as you know, that two year bipartisan budgets agreement we reached in february provided major new investments to address the opioid crisis, childcare and

early learning needs and more. so we need to hear the administration -- we now hear the administration is going to submit a second rescission package and undo many of the investments. i want to make it clear today, we'll vigorously oppose any effort to undue the bipartisan deal the president signed in law. both sides made a commitment to that deal. our side didn't get everything we wanted. neither did the republicans, but a deal is a deal. any attempt by the administration to break its promise by recinding or failing to spend the omnibus funding is major breach of faith. so in addition to asking about your budget request, i'm very interested in hearing how you plan to implement the funding increases we did include in the omnibus especially responding to the opioid crisis and childcare. i was glad to see your budget at least maintains the level of funding congress directed the administration to spend, $10 billion in multiyear funding for activities related to the opioid

crisis. of that amount, you're proposing to allocate $2.8 billion to agencies funded within the bill. as you know, chairman blunt and i agreed to increase funding for the childcare and development block grant by over $2.3 billion, almost double what we spend now to help improve childcare options for struggling families and agreed to increase head start by over $600 million. i have heard from families in washington state and around the country about their struggle to find and afford quality childcare so i'm really glad we were able to take a step in the right direction. and i hope we can keep working to increase investments in childcare and early learning so every parent can afford childcare and every child is prepared to succeed in kindergarten and beyond. it's not only the right thing to do, it is a smart investment for families, communities and the economy. it is one of the many urgent issues facing families that democrats and republicans should be able to come together to address like the alarmingly high

maternal mortality rate or the epidemic of gun violence and the lack of research into this issue which you yourself, mr. secretary, have said is a priority. and democrats are going to keep making the case that we should take steps to actually help families address these problem instead of proposing cuts that do the opposite. and we'll keep urging republicans to work with us to make that happen. so mr. secretary, i look forward to hearing what you have to say on the issues and discussing any of my concerns further during the hearing. >> thank you, senator murray. we're pleased that you bring your skills and your dedication to this area to the job you're doing. and you've done a the lo of things that other people would not have been able to accomplish even in the last few woochlt glad you're here and look forward to your testimony. chairman blunt and ranking member murray and members of the

committee, thank you very much for inviting me to discuss the president's budget for the department of health and human services for fiscal year 2019. and also my personal thanks for being willing to reschedule in light of my recent illness. thank you for that accommodation. it's an honor to be here. it's an honor to serve as the secretary of hhs. our mission is to enhance and protect the health and well-being of all americans. it's a vital mission and the president's budget clearly recognizes that. the budget makes significant strategic investments in hhs' work. the budget requests $34.8 billion for the national institutes of health, $5.8 billion for the food and drug administration and $2.8 billion for priority biodefense and emergency preparedness programs. the president's budget especially supports four particular priorities that we laid out for the department. issues that the men and women of hhs are hard at work on already. first, fighting the opioid crisis. second, increasing at fordability and accessibility of

health insurance, third, tackling the high price of prescription drugs and transforming our health care system into a value based direction. it supports the work that hhs does to keep america safe from disasters and diseases. the president's budget brings a new level of commitment to fighting the crisis of opioid addition and overdose that is stealing more than 100 american lives from us every day. hhs has given resources. they would invest $3.5 billion in fy-19 to address the opioid epidemic and serious mental illness. within that allocation, for example, the budget dedicates $1.2 billion to the state targeted response to the opioid crisis grants. and invests $150 million specifically to con front the crisis and high risk rural

communities. recognizing with he need new tools and private sector innovation to defeat this ep depic, the budget proposes $500 million to continue the nih public-private partnership to develop new addiction treatments and nonaddictive approaches to pain management. the budgets also supports programs that have a proven record of improving the lives of americans who suffer from serious mental illness. we're pleased that congress including members of this committee responded to the president's call for these invest mepts choosing to boost hhs funding to con front the opioid crisis in the recent omnibus spending bill. the second priority is our commitment to bringing down the skyrocketing costs of health insurance, especially in the individual market. the budget propose that's transfer of resources and authority from the federal government back to the states empowering those close to the people and bringing balance to

the medicaid program. third, prescription drug costs in our country are simply too high. list prices are too high. seniors and government programs are overpaying due to lack of negotiating tools, out of pocket costs are too high, and foreign governments are freeloading off of our investments and innovation. to address the problems, they propose a five part reform plan to further improve the already successful medicare part d program by straightening out incentives that too often serve middle men more than they do our seniors or the government program. the budget also proposes medicaid and medicare part b reforms to save patients money on drugs and provide strong support for fda's efforts to spur innovation and competition in the generic drug market. we also want our entire system to pay for health and outcomes rather than procedures and sickness. our fourth departmental priority is to use the powers we have at

hhs to drive value based innovation throughout the health care system. this takes steps towards that shift laying the groundwork for the vision i announced this spring. our system may be working for entrenched encouple bents but it is not working for the taxpayer. i want to highlight the budget's investme investments to keep americans safe from disasters and diseases. the budgets funds a continuation of the successful public-private partnership and already launched 35 fda approved products since the establishment in 2006. the budgets also provides u.s. support for the global health security agenda, an effort to build other countries response capacity so we can prevent infectious threats frefer reaching our shores in the first place. the president's budget will make the programs we run really work for the people they'rement to serve including by making health

care more affordable for all americans. it will make sure our programs are on a sound fiscal footing that will allow them to serve future generations too. it will make the investments we need to keep americans safe. dlifing on t dl delivering on the goals is a sound vision for the department of health and human services and proud to support it. thank you and i look forward to the committee's questions this morning. >> thank you, secretary. we'll have time for second round of questions. other members will come later. so as much as possible, let's try to stay within five minutes on our first round. and if you have more questions and want to stay, that will be great. if you have more questions you want to submit to the record, that would be acceptable as well. let's just start with pharmacy costs. you mentioneded some key principles there. i know the administration is going to have major announcement tomorrow. can you put just a little more detail on the key points that you've already made today? how those could be used,

medicare part d and otherwise snt middleman issue? anything you want to explain to us further there would be helpful. >> you bet. thank you. what we want to do is, of course, we want to balance the need to support innovation and the development as this committee is very committed to of the next generation of therapies for our people in the people of the world. but want to balance that with access for patients and very importantly we make sure the prescription drugs are affordable. on that affordability front, we're trying to address four key problems. the first is list prices. the list -- every incentive in the system is towards higher list prices. how might we help reverse the incentives on list prices? the second is ensuring that our programs are up to date in ensuring we get the best deal possible for the drugs so negotiating the best deals possible and ensuring our programs have those tools. the third is ensuring that there is adequate competition. at the end of the day, multiple

products, multiple generics and branded products, swift entry of generics ending any patent gaming that prevents generic entry is critical to long term price reduction in our system. and then the fourth area is our patient's out of pocket expenses. we've seen changes and transformation ands insurance design over the last sec adecad patients are asked to assume more of the cost of drugs when they show up at the pharmacy or get the bill at the hospital or doctor's office for those drugs and how do we address that out of pocket? so those are the areas we're going to be focused on tomorrow when the president rolls out his game plan. >> yeah. i would say on the list price versus the net price issue that whatever we do here needs to always also keep in mind people who aren't on any government program, people who for whatever reason haven't been able to afford or have chosen not to

have an insurance plan that they thought didn't meet their needs and they're the ones that more often than not are at least initially asked to pay the list price that virtually nobody else is paying and we need to be sure we're aware of that at the same time on durable medical equipment, mr. secretary, you've been forward leaning and trying to help solve that problem. and our state and missouri there are a lot of urban missourians, suburban missourian who's live in communities that have lots of options. they can shop. there is competition. there are lots of missourian that's don't have that at all. in fact, i think in june of 2013 we had 199 suppliers of durable medical equipment. many of them -- the only supplier in rural communities. we're down now to 152. i think the office management and budget just released a rule that you sent them last year. what will that do to encourage

people to continue to provide the kind of medical equipment that allow people to stay at home rather than their other option which is much more expensive for taxpayers in most cases of the nursing home that leads to medicaid and all kinds of federal costs where durable medical equipment being available often can make the difference in whether that happens or not available and supported by somebody who is a phone -- who is able to really support the equipment. >> well, mr. chairman, thanks you to and other members of the senate and house, we appreciate always being aware of the concern on rural durable medical equipment and impacts that the reimbursement program is having on them. and that inspired us to act with the rule we put out yesterday that we hope will provide relief to rural providers. ensuring that access is absolutely vital.

to not do so can be penny wise, pound foolish. >> i think you established a rate for most of the rest of this year. what do you expect to happen after that? >> so what we're going to do is we want to take the learnings. we had been on track for 2019. but we actually put a pause on that to make sure we take the learnings from this experience of what we've seen in terms of what happened to rural durable medical equipment and in the rule that came out yesterday, we come up with a 50/50 plendblend rate that will provide a lot of relief to the rural providers. we've also in the budgets asked for two choifrpgs hanges. the first is we would pay winning suppliers, winning bidders at their bid amounts rather than at the lowest bid. there were some bottom feeding behavior going on that was making it unsustainable to be a dne supplier even if you won the bid. and the second is to expand competitive bidding to all areas so that the bids are localized.

so a rural provider isn't being judged and paid on whatever, for instance, an urban community bidding process would have resulted which was the challenge under the current system. so we are very open minded. we want to miake sure this program works. rural dme is important. we seek any input and want to work with both sides of the aisle to just make sure 2019 works better than it has. >> thank you, mr. secretary. i'll have more questions later. senator murray? >> thank you very much. again, thank you for being here today. i want to ask about title 10. it is the only federal program dedicated to providing family planning and related preventive care including birth control and lifesaver cancer screenings to uninsured or underinsured and low income people. every year title 10 providers serve more than four million women, men and young people. now while your budget does maintain the level funding for title 10, as democrats and republicans agreed to in the spending deal we just reached

and sent to the president, your budget actually would undermine access to care by attempting to exclude planned parenthood from participation in this. they provide basic hg serviealt service to 2 million patiented. they serve the targeted population than any other title ten funded provider including foreign patient who's receive contraceptive care through the program. so, mr. secretary, do you think the federal government should be in the business of telling women which doctors they can and can't see? >> so senator, we share your prioritization and concern for the title ten program. as you said in our budget we funded it at a level amount. and we want to ensure that program works for the women and men who are able to make use of it. we want to make sure we have a robust group of providers that are available, that were able to reach people so that they get the services. we want to ensure it reaches a broad range of family planning services which, of course, is the mandate in the title ten

statute. and so we want to have a diverse group of suppliers, of grantees and we want to make sure we have the full broad range of family planning services available. >> can you commit to maintaining a network of safety net providers that will deliver the full range of high quality family planning services to four million people nationwide? >> so we believe that whatever we would do with title ten will ensure appropriate access to title ten services as well as broader services more generally. our grant process is actually seeking out a broad reach of providers and grantees who would be available for individuals. >> i hope that you will make the commitment to not remove a provider that actually provides 41% of the currently served and we'll be watching that very carefully. let me ask you about aca. as you know, president trump cam panld on the promise to guarantee affordable health care for everyone and protect people with pre-existing condition. it has been really disconcerting

to see this administration sabotage the health care system in many ways driving up premiums and recent study showed that millions more people are becoming uninsured. so i'm concerned that now in another attack on patient's health care, hhs is proposing to expand the sale of short term junk plans that allow insurance companies to deny coverage to people with pre-existing conditions and exclude essential health care benefits like cancer treatment or maternity care. many of the junk plans spend as little as 50 cents of every premium dollar they collect on actual medical care, spending the rest on executive compensation marketing and overhead. federal protections ensure that no one can be denied coverage or charged more based on their health status. i want to be very clear. your rule undermines the critical protections. do you know, do you agree that the short term plans your rule

is promoting are allowed to deny coverage for individuals with pre-existing conditions or charge them higher premiums or exclude these critical benefits? >> we share the goal. we want people to have access to competitive affordable health insurance. unfortunately, the affordable care act is not delivering on. that we want to keep working with you on changes to make insurance affordable for individuals. but pending legislative changes, we want to make available to individuals who have been the $28 million men and women who have been forgotten and forced out of that market, some kind of option. it may not be the right option for everybody. we want to be very transparent about that. for some individuals, it may be better than nothing. and so these same short term plans are what the obama administration had for eight years. >> those are short term. and the short term plans guarantee none of the critical consumer protections that are included in the individual insurance market. coverage for hospitalization,mental health and substance use disorder. actually a recent report found

one that doesn't cover hospital stays on weekends. so what your propose will rule extend the short term plans when deny the coverage to a full year. so i'm really concerned that part of what is driving up premiums today is this rule and i'm very concerned that families who enroll in the plans will will have no idea and will be stranded without coverage when they're sick. so again this is something we'll be following very carefully. thank you, mr. secretary. >> senator alexander? >> thank you, mr. chairman. welcome, mr. secretary. senator murray and i agree on many things. one thing we do not agree on is health insurance. for example, as you just said, the short term plan she's talking about are the same short term plans that xifexisted throughout the entire obama administration. i want to congratulate the administration on the proposal that has the prospect of letting small employees of small

businesses have a chance to have the same kind of insurance that an ibm employee might have at a much less of a cost. and with the same protections. you couldn't be charged more because of a pre-existing condition. you couldn't have your coverage denied because of a pre-existing condition. your kid would have -- you'd have to give coverage to your kid up to age 26. couldn't be lifetime limits. so those -- and in addition, rates didn't start going up with president trump. they started going up with president obama in 2013 with the beginning of obama care. they went up 176% in tennessee since 2013. and we had a proposal which a month ago president trump asked speaker ryan and senator mcconnell to put in the spending bill. they agreed. they said it would have reduced rates by 40%. it wouldn't have changed essential health benefits. it would have allowed coverage

for pre-existing conditions. no lifetime limits and the democrats blocked it. so that's a difference of opinion we have about who is responsible for the high rates which are coming because of obamacare and democrats blocked our proposal a month ago. now one area we agree on is the urgent need for response to the opioid epidemic. senator murray and our and mcome reported a bill a few weeks ago with contributions from 38 senators with more than 40 proposals to attempt to give states and communities and doctors and hospitals and judges more tools to deal with our largest public health epidemic. have you had a chance to review that bill and does the administration support it? >> thank you, senator. thank you for your commitment around helping to make options more affordable for individuals under the affordable care act. and also we thank the committee and the congress for the bipartisan work on opioids.

i reviewed some elements of the bill. i've been briefed on them. the administration doesn't yet have a formal position, as you know, to state on the legislation. but there is so many very good things in there that i'm sure we'll continue to work together and we'll work through the process of deciding on administration -- >> can you give it your priority snt house of representatives is working on opioid this is month. they hope to produce a bill. i hope our bill can go to the floor this summer, have contributions from other senators. we have invited many of them from other committees to meet the witnesses at ours and we would hope to be able to deal with this problem this summer. let me move to something called the medicare area wage index. this is an index which has a big effect on how hospitals are reimbursed. the 5500 hospitals in the country. and from our way of thinking, there is a big unfairness

because of the wage index, for example, if a hospital in connecticut is billed $100 to medicare next year, it would receive about $126. but if a hospital in tennessee billed medicare for $100, it would receive $82. and as a result of that, a number of us in states, because of that discrimination introduced legislation to try to adjust the hospital area wage index because it's causing hospitals to close. cms announced a rural hospital initiative but it didn't include any relief from the area wage index. have you thought of ways to adjust the area wage index to, one, make it fair and to especially foes

especially to focus on rural hospitals? >> the wage index is one of the more vexing problems in medicare and adjustment for any one state on the wage index hurts other states and leads to this constant back and forth of winners and losers there and we have and the prior administration have suggested to congress that we would like to work together to come up with statutory changes to adjust the wage index approach, ensure better equity. every year we deal with many challenges. in particular, some rural areas. but we have issues constantly. so we welcome the chance to work with you and others on appropriate reforms. >> my time is up. i want to conclude by saying one other area we agree on in this committee and senator blunt and senator murray deserve great credit for their leadership is focus on biomedical research and the funding for the national institutes of health. we hope to continue that. >> thank you, senator. senator durbin. >> following up on that, thank you, mr. secretary. i want to thank the three senators to my left for their

leadership on medical research. i'm disappointed that the president's budget calls for reduction of $66.2% in spendingt the nih. i hope we have the wisdom to ignore that suggestion and continue to move forward in critical medical research. 32.5% decrease suggested by the president's budget for the centers for disease control is equally vexing when you consider what we face now across this country in terms of public health ch health challenges. i'm counting on my colleagues. i hope congress can show a better approach to the administration. let me ask you to join me and thinking for a moment about the issue of addiction today. i spent a major part of my reason for fighting big tobacco

for family reasons and personal reasons and public health reasons. there are indicators that we started moving just slightly in the right direction. we have seen a decrease in tobacco smoking in kids from 28% in the year 2000 to 8% in the year 2016. that's dramatic. because we learned that if you don't hook kids early while they're making the wrong decisions and immature, it's very difficult to convince them to become cigarette smokers later in life. good news. now let's talk about the bad news we face. we know from the opioid crisis that it strikes everywhere. not just in the inner city. but in wealthy suburbs and small towns. i can prove it. in my state, i can prove it. everyone can prove it in their state. it is the worst drug epidemic we faced in america, period. now it is morphing into a new version of that epidemic that is

even more frightening with the use of these synthetic narcotics. they can be produced in a laboratory over a span of i understand a 48 hours in the united states. it's no longer a question of the poppy fields growing somewhere around the world. it's our backyard and people to make this and kill them with this sen thetic drynthetic drug. there is another adestruction. on your watch that is becoming alarming, between 2011 and 2015, the use of e-cigarettes among high schools increased more than tenfold from 1.5% to 16%. in my state of illinois, 27% of high school students are using vaping devices and e- cigarettes. i talked to dr. gottlieb about this. whether we con front the industry, they say, no, this is about getting people off of

cigarettes on to vaping which is not as dangerous. well, that might make sense. maybe that argument might have merit until we learn at the products that are for sale. let me show you some of the products for the record. these are vaping products available, supposedly for adults. adults to get off of using tobacco products. jam monster. a blueberry packaging flavor and they say it's the same as jam, butter and toast. ears another good one. soft serve ice cream flavors. then when it comes to flavoring, cupcakes, raspberry yogurt cupcakes. raspberry jelly. but the difficulty we have is that these are becoming so pervasive, so insidious, so fast that when the fda says we'll get around to this in four or five

years, we don't have the time, mr. secretary. we don't have the time. we need to commit ourselves to stop this. did you read "the washington post" this morning? they're talking about saying that kids in the schools in the suburbs here can't bring flash drives to school yaen moanymoree it looks like a vaping product. they're taking doors off the bathroom stalls in schools because kids are going into the stalls to vap during the course of a day. this is a galloping addiction and one that is affecting children across our country. my obvious question to you is, what's this administration going to do about it? >> well, thank you. we share your goals here, totally. and in fact just last week the fda went after i don't know if it's the precise products, if not, they will be. these products that are clearly being marketed towards and aimed towards children. we are going after them. we will go after them. while the commissioner has laid out an agenda that tries to

balance having alternative nicotine delivery devices available as a means for exiting combustable addiction from cigarettes and other devices, we must ensure that these alternative nicotine delivery devices are not marketed for or become an entry point into tobacco, exactly the concern that you're expressing and we will be very -- we'll be very vigorous in going after these -- any bad actors that are trying to market or aiming towards entry points for children or others into addiction. so i think we're completely aligned. we need to just talk. we want to ensure that we get adequate regulation and that we develop this space of the exit path for customerable tobacco. we want to make sure that develops but done the right way uncompromising in terms of any kind of entry path for children or others into tobacco addiction. we would share that goal completely, senator. >> i'll tell you, while we --

the jury is out on this conversion from customerable tobacco to vaping and whether that is a lidge military purpli f -- legitimate purpose for this, the hooking of our kids is unmatched. i don't think there is a sense of emergency or urgency in this administration yet for something that could end up being sadly part of your legacy to have stood by and watched as the percentage of kids in america became addicted, hopelessly addicted to nicotine through these products. >> thank you, senator durbin. >> i appreciate the comments. i agree completely on the issue of vaping and things targeted towards children and the opioid epidemic. i look forward to working with the secretary and with all of congress on that issue. as well as what i would raise as an issue of congress has been kind of double minded on the issue of one point promoting

marijuana legalization and the other point trying to go after vaping. and so i would hope that we would speak with a consistent voice on these issues that marijuana encouraging more people to use marijuana doesn't exactly help us either. long term and then we should be consistent on our message that's not say that opioids are bad but marijuana is good. let me go back to one of your comments earlier you made from the opening statement. you talked about the middleman in prescriptions. i assume you're talking about the pbms. that is the big issue and a major driver of cost. obviously when the epipen conversation came out for the first time, millions of americans heard about pbms and it's been an issue. where is that going in the on going conversation about how the dollars for any of though prescriptions are getting to the producer or dealing with the consumer, the person delivering it and the pharmacy but not to the pbm in the mid snl. >> thank you for asking about that. that will be a focus of the president's announcements

tomorrow is addressing every element of the pharmaceutical pricing channel including those who negotiate for so many of us, the pharmacy benefit managers, their role. they serve a very important role. >> sure they do. >> but i think it's very important that we address the incentives that are in the system. who are they working for? who are they being paid by? and where do the savings go to? >> right. it's been clear that insurance companies are purchasing pharmacies in such to get access to the pbms in the middle seeing that becomes the path way to actually greater profits is to be able to own that pbm. as you mentioneded in your opening statement about competition, examiif competitio important, local pharmacies are important. let me ask you a perspective. for a local pharmacist and they're trying to recapture these, how do we protect the local pharmacy in rural areas to make sure we still have those local pharmacies that not everything is mail order but

patients have the opportunity to be able ask face-to-face questions and not trying to go back six months later and recapture things? >> i'm glad you raised this issue. it is something on my radar and concern for me. i'm going to actually ask our inspector general to enshoo you are that he's inspector general to be sure that he's looking into this question. the issue you're raising as i understand it is often where you have these large pharmacy benefit managers that own their own mail order specialty pharmacy but they have to interact with local or nonowned specialty pharmacies are these dir fees, essentially taxes imposed differentially and unpredictably on those independent pharmacies in a way that puts them at a competitive disadvantage from the owned ones. i think this is an important issue worthy of study because there should be a level playing field and there should be good competition. so i'm going to ask the i.g. at hhs to look into this issue. >> i appreciate that very much because that is an issue and it's typically months later when they find out about the dir fees

so a local pharmacy will charge a client $10 for a pharmaceutical and then a dir fee comes back that's a $9 claw back on it six months later that pharmacy is long gone, they are not going to go back to their customer and say i undercharged you on this. it's become a big issue for them and is a rolling issue. it's related to what senator alexander was talking about with the wage index. the device that they may put in, whether it be a pacemaker or a valve, whatever it may be, the device is that same cost whether you are in oklahoma or new york city, but in oklahoma the cardiologist makes a tiny amount because most of the costs of reimbursement is the device, while in new york city the device which has the same cost, the cardiologist gets a very large amount. so what happens is if you are a cardiologist your tendency is to be able to move to the east coast where you can get paid more for the same procedure. if we want to have fair medical treatment for everyone across

the country we have to be able to balance out not just the cost of the device and reinforcement but also what the doctor themselves is being reimbursed. let me mention to you about the rural hospitals, we have multiple areas i'm going to try to chat with you about because some of them are issues that you all are dealing with like the abortion surcharge that's ongoing that obamacare at the very earliest days says that has to be a separate billing amount but it obviously has proved not to be so and will be one of those things i want us to work on to be able to establish. for rural hospitals in 2015, 15 hospitals were designated as vulnerable rural hospitals. by 2016 we had 42 hospitals that were designated as vulnerable. by 2017 we have 41 hospitals but at the same time four of those hospitals are closed. we have major issues that are rolling out with the affordable care act over the years that is disproportionately hit those rural hospitals. i know y'all are making some recommendations on this, i just want to be able to say this is of epic importance to rural

hospitals that we do resolve some of the issues that we have there and reimbursements, telehealth, all of those things that become so important, we're losing emergency rooms and we're losing access in rural areas and that will be exceptionally important we deal with that. >> thank you, mr. chairman. >> thank you, senator lankford. senator manchin. >> thank you very much, mr. chairman. thank you, secretary, it's good to be with you. first of all, we finally got a bill called jesse's law and i think i sent you a letter on that and i want to follow up on that because it's just a common sense piece of legislation, this beautiful girl jesse grub as you know had an injury and she was an addict and she was trying to clean up and she was doing very well in rehab and went -- had a running injury and went to a michigan hospital and she told the doctors her parents were with her and she was so proud of being a recovering addict and wanted to be careful about her

markings on her -- all of her transcripts as far as her admission to the procedure she was going to need. to me i just thought it was common sense that we market as if are you allergic to penicillin, something very critical. it wasn't. she got discharged, discharging doctor didn't see it, gave her a prescription of oxycontin and she had overdosed by that evening and died. so what we're saying is this piece of legislation you all have it now to set some guidelines and rules making sure that the procedures -- so i think what i need is -- and i know you feel the same committing your agency to begin work on this -- on these standards and as quickly as possible medical professionals all over the guidelines will have guidelines of how they mark when there is a patient coming in identifying themselves of this nature. have you all started or have you received that in the office or have you -- >> so i have not been briefed on

our efforts in response yet, but i can assure you that will be a high priority for us. we share the goal. we want to make sure -- >> this is -- this was all preventable. senator kacaputo is a co-sponso with me on this. they want to make sure that this beautiful little girl didn't die? vane. it's called jesse's law, it was in the omnibus bill. we have a letter on that. i know senator capito's staff would be the same, anything we can help you with. people say how come i can order drugs from canada and get them so much cheaper? why are drugs so expensive? why are pharmaceuticals charging so much? why are drugs protected for such a long period of time before they're able to be sold as cheaper generic drugs. the whole pricing structure, the pbms, the purpose of pbms are you all looking at that? they're telling me it's the pricing structure and how we sell drugs to the consumer is

what the cost is so much different than anyplace else in the world. >> so tomorrow the president will be rolling out a comprehensive plan around drug pricing that addresses all aspects of the channel including the role of the pharmacy benefit managers, drug companies, others in the system, highlighting exactly the types of issues you're raising and also going after this question of foreign governments that free ride off of american investment -- >> would you say, secretary, that a lot of the pricing in america being some of the highest cost in the world as far as for lifesaving drugs and drugs that are needed for quality of care for people, is it because of the pricing, the way we sell it, the way we get it to market that's causing that chain reaction? >> so i don't believe it's the selling and marketing is the reason. it's basically government structures and payer systems and what happens in the united states, some of our plans and some of our approaches actually drive as good or better deals than some of the socialist

systems abroad and then in other parts of programs and for other medicines foreign governments, socialist, single-payer systems get a better deal. now, often that deal comes at the cost of rash thing and access and patients who are suffering from cancer or hiv/aids or ms or rheumatoid arthritis they can't get access to the medicines that you can here in the united states because that's exactly what the socialist systems do. so it is a balance, but what the president is going to be doing is trying to tackle the elements of our program, how do we make them better so that we pay less and of course get foreign governments to pay more. >> i have to hurry up. i look forward to that report tomorrow and if we can start down the path to get cheaper drug prices and access to those cheaper drugs -- drug prices on the market in america will be very helpful to west virginia. we have in west virginia the largest per capita per capita burden as far as opioid deaths.

the amount of money how it was being disbursed before was not based on the amount of rate of per capita deaths that you had it was based on population. senator capito and i have both been working with this. we need to make sure the money is getting to the front line. you have a war on drugs, we are the front line. we are on the battlefield every day and states like us in different parts of the country. are you all -- have you all recognized and are you directing the money to come to that areas of need? >> yes. thank you for that concern and we appreciate the flexibility that this committee and congress gave us in the omnibus and appropriations bill to actually target money towards the highest burdened states on opioids and we will faithfully -- >> we have 15% set aside but that depends on how quickly and how capably you all are able to administrate that to make sure it gets to that front line because we are in need. we are very much in need. >> senator kennedy. >> thank you, mr. chairman.

mr. secretary, how are you? how many -- how many people are on medicaid? >> the actual numbers on medicaid -- you know, senator, i want to make sure i've got that exactly. 70 million. i'm sorry. >> all right. do you know anybody on medicaid who is able to work or on any social program who is able to work, and by "able to work" i mean not elderly and not disabled, to doesn't want to work? >> i certainly hope all would. i hope all would. i view -- i view those being able to work and working as such a -- where one is able -- as such a fundamental aspect of one's own dignity as well as we think healthcare. >> we can agree with all that. i don't know anybody -- i mean,

there may be -- i'm not saying there aren't folks out there, but i've never talked to a person on medicaid who was able to work that didn't appreciate that he or she would be better off with a job and being able to buy their own health insurance. i've seen numbers that show we have 28 million people on medicaid who are not elderly and they are not disabled who could work if they could find a job, but don't work. i've seen numbers that show we spend about $150 billion a year on that subset. i've seen numbers that say about 40% of those 28 million don't have children. i think part of the problem is that many of these folks -- i'm

not saying all, i mean, i'm not naive -- but many of these folks would like to know the dignity of work, but they need a little help about getting that job. now, the economy is rocking, i think it's because of our tax bill. i know there are some who disagree with that. i don't understand why the administration does not loudly and aggressively say, look, the free market -- by that i mean being able to get a job -- has done more to lift people out of poverty than all the social programs put together. and if you don't believe me, i give you china. it's not the communist party that lifted so many of our -- the people of china out of poverty, it was because they adopted a form anyway of

capitalism. and i don't understand why the administration -- and i wish you would take this back to the president because i think he will agree with me -- doesn't say, look, we don't want to throw people out in the cold, but we want to help them understand the dignity of work. it's a win/win. it's better for our fellow americans to know the dignity of work and it's better for the american taxpayer. and let's put together an aggressive program that's not optional for the states. my governor doesn't want to do it. my governor -- i believe in more freedom. my governor believes in more free stuff. that's just the way it is. i'm not criticizing him, i'm just describing him. but put together a program not to throw people out in the cold, but just to say, look, let us help you get a job. you can keep your benefits, but let us help you get a job.

if your children are older we will help you get that job, we will point you in the right direction, we will help you find a way to get to work, you can -- you've got to do it for 20 hours a week. you can keep your benefits. you will feel better about yourself and let's do it. i appreciate that cms is willing to grant waivers, but why don't we take the next step. why don't you take the lead on that. >> well, i believe the president has led boldly here with the welfare reform executive order with what we're doing in medicaid -- >> how about we pass a bill. >> we would work with congress, snap, the snap program, the president has wanted work requirements in there. >> but they're optional. it doesn't need to be -- sorry for interrupting, i'm not trying to be rude, i'm really nod, but we've got -- see, i'm down to 11 seconds. we don't need to make it optional and we need you to take the lead and the president. i mean, the president is kind of busy right now, he's working on

a lot of stuff. i'd like you to take the lead and cms to take the lead and say this is a win/win and we're not throwing people out in the cold, we will let them know the dignity of work. taxpayers will be better off. they will be better off. and it's not going to be optional for governors. sorry, mr. chairman. >> thank you, senator kennedy. senator murphy. >> thank you very much, mr. chairman. i know senator alexander isn't here but i just want to make a note for the committee and for the secretary on the reason why we have the wage differential, i say it because senator alexander referenced the difference in payments to connecticut and to tennessee. we are a big country, we have different costs of living, we have different rates of pay from state to state and that is the reason why medicaid, medicare reimburses slightly differently. it of course results in the average connecticut taxpayer

sending $14,000 to the medical treasury and the average tennessee taxpayer sending about $8,000 to the federal treasury if we are interested in equity and parity we would be more than had a ep to adjust tax rates to send $8,000 to the federal treasury instead of $14,000 and if that was the deal then maybe we would be happy to accept less in medicare reimbursement, but there is a reason why you pay a little bit more for medicare in connecticut, it's also the same reason why the federal treasury gets a lot more from connecticut. i point that out for the record. i want to continue along the line of questioning from senator murray, mr. secretary, on this campaign of sabotage that has been wanld by the administration driving up rates all across the country. this is a quote from the head of the largest health insurance company in maryland talking about why they were going to be dramatically increasing rates, especially for plans that tend

to be used by sicker patients. he attributed these rate increases to the continuing actions on the part of the administration to systematically undermine the market and make it almost impossible to carry out our mission. in making that statement he talked specifically about ppo plans which are favored by sicker patients, people with chronic illness and, in fact, in one of those plans in the recent rate filing premiums went up by 90% in maryland. so it gets me to this question of the short term. what we would call the junk plans, the short-term plans, and the effect that it will have on the market. the worry of course as you know is -- and the reason why president obama moved the time duration down to three months is that because these plans are not subject to the requirements that you cover people with preexisting conditions the same, that you have a minimum standard

of benefits, you have a migration of healthy people to these plans and you would leave all the sick people, people with preexisting conditions, behind, and i think you're already seeing that in the price increases on the exchanges. so that's the reason why the obama administration said, listen, we're going to make these short-term plans actually short term, three months. so how do you gauge what insurance companies are already predicting that there will be a massive migration of healthy people into these short-term plans that, you know, are now effectively a complementary option to the exchanges driving rates up for people with preexisting conditions, people who -- who simply can't go on those plans if they don't cover everything that they need. >> senator, first, good to see you again, and i would say first it's important to remember that what's been proposed nothing is final but what's been proposed on the short term plans is to

restore what president obama had in place until the eve of his return in office. he kept 12 months in place the entirety of his presidency in the program. it's next important to remember that of the about 10 million people in the individual market over 82% of them were buying their insurance for them, they're subsidized, people are not going to be leaving subsidized insurance with the full slate of benefits for the short term plans. the individuals that these plans will be available for and it's going to make sense for are folks left out in the cold by the affordable care act now, those 28 million folks who are sitting out there that can't afford these skyrocketing price increases that happened around president obama in his own plan, we are just trying to make options available. they are not going to be right for everybody. we're being very transparent about that. but want those as options for those if it makes sense for them, but what we really have to be working on together is fixing what is wrong, what's not working here, which is the affordable care act, it's not delivering the price increases were happening before president

trump, they're continuing, it's not functioning and we want to come together with a new system. >> it's not true it's not functioning even with this deliberate campaign of sabotage, even with the administration stopping to market this plans, even with the administration refuse to go pay for the navigators, the same number of people signed up last year that signed up the year before. i don't think that will continue because at some point 90% price increases are going to force people off no matter how big the subsidies get. so i'm very worried, mr. chairman, about the separation of the market into very healthy and very sick as these short term plans now become, you know, true viable options right next to the exchanges. i look forward to continuing the dialogue. thank you, mr. chairman. >> thank you, senator murphy. senator capito. >> i'd like to follow up on a

consider question that my fellow senator from west virginia talked about. you and i have talked about this and that is trying to market the 21st century cures dollars to the tip of the spear where we have the highest age adjusted mortality rate in the country. i just want to ask for a clarification because my understanding is when we talked about this and that the last tranche of money that went out went out on the old formula basis but the next tranche of money that's coming out in september/october will have this target adjusted. could you kind of confirm that for me and maybe explain a little better. >> absolutely. thank you, senator. as i mentioned to senator manchin, we appreciate both -- there is the targeted hold back from the omnibus of, i think, 15% if i remember correctly that is deliberately targeted to the highest burdened states, but in addition we appreciate the flexibility that congress gave us now on the remainder of the money that we would put out in

september to also with regard to that money try to focus it on the highest burdened areas of the country. so i think on both sides of the fence there would be our -- would be our goal to target where most needed in the country. >> i think that makes a lot of sense and to those of us in states who are not as highly affected as our states are at the very beginning, if we don't nip this in the bud where we are and find best practices unfortunately i think it's going to cascade in the numbers that we see in our area. another area of concern that i have, we see a lot of money going into this, a lot of recovery and treatment and i welcome all of that from drug courts, assisted treatment to help with foster families, et cetera, et cetera. i do have in the back of my mind a concern and we've seen some news reports where recovery centers have sort of sprouted up without the proper oversight as

to what type of treatment is being optioned, what kind of recovery programs. in some cases i believe there was a case where in the treatment program the person who was in charge of that or the owner of it was actually giving the users more drugs to keep them sort of at bay. so i don't know where your quality control is on this. is it more at the state? is it your level and what you all are doing about that. >> so i'm glad you raids that. it's a really important question and that's something that evan auto on the last round of funding that went out, the 400 and i think 95 million dollars that went out a couple weeks ago, samsa imposed conditions there, for instance, that the money could only go to treatment centers that used medication-assisted therapy. because we know that works and it ought to be available if the precious money that the congress has allocated is being spent there. we're going to keep looking as we move forward to september

again on best practices, best approaches. i want to be collaborative but we also want to make sure this money doesn't just get spent any which way but those towards the real approaches that are going to work to help solve this problem. exactly the kind of situation you are talking about. learning process for us primarily state regulation but we of course through the grant process as we release the money can impose conditions on that, on how that should be spent and as we learn, get input from you and others what's working and not working and where there are risks of a butte we want to take advantage of the opportunity. >> i welcome that. i would also say our local west virginia we have recovery place and we also have ray of hope that are abstinence treatment and they have some success here and a lot of success. so i think we just need a quality of reassurance that we are not getting pop ups around to solve a very deep and devastating problem. the other area of concern for me

in health and it's such a large area in general is alzheimer's and what we're doing in terms of treatment research, helping caregivers, quality of care, all the things personally touched by this in my own family as some of us are. from the department's perspective, i know you're doing research, i know you're kind of -- medicare is trying to help with some of these issues. what perspective can you bring to us today? >> well, of course, we have a comprehensive and deep commitment around alzheimer's just as you do. at nih with the money that this committee fortunately at cates to us i think we're currently supporting over 140 clinical trials and that's an area i happen to be quite familiar with also. >> right. >> we need to keep looking in the medicare and medicaid space to see ways that, again, my theme of not being penny wise pound foolish, other ways that we can support caregivers and others in nontraditional ways to ensure that we avoid perhaps

early institutionalization of individuals. >> right. >> and so i'm open for whatever -- any ideas and breast approaches that we can take across the board, also on our payment side how we can help the families dealing with this devastating disease. >> senator schatz. >> thank you for the conversation the other day. i want to talk about something rare, something we all agree on and that is telehealth. you said you are a big supporter of telehealth. i'm pleased to be able to work with you on the implementation. we had -- we still have a bill called the connect for health act which is bipartisan and bi-cameral. about half of it was enacted in the last cr. we will make good progress in that space lifting certain restrictions around medicare, but kind of the last piece and for me the holy grail is to give the secretary waiver authority

assuming his or her actuaries determine that waiving barriers to telehealth around medicare would pay for themselves and so i'd like you to talk about how you would use that waiver authority and how it would expend access and reduce cost. >> thank you for the discussion we had on this. i do think this is a bipartisan area where we can all get together whether it's in rural health, remote frontier health or just containing cost and being efficient is the work of telehealth and the biggest challenge is our payment systems are frozen in the 1960s. so often in medicare and medicaid. now, in using -- if i were to be given that authority probably the single biggest countervailing pressure we have is of course integrity and ensuring program integrity through telehealth that we don't see abuse. i think so many of the rules that we have are some bad provider did something so you put a rule in place. obviously we have to do it with

respect to the taxpayer program integrity, but i would want to be very forward leaning here on implementing any authority to, again, penny wise, pound foolish. use telehealth, expand the network of providers, expand the reach to communities, really help in rural and frontier communities and lower the cost of care. i'm with you on this one. >> thank you. i think reaching veterans, reaching people in rural communities, helping with the opioid crisis, asthma, psychiatric, psychological treatment, all of it can be done through telehealth and i think the transformation in our society is that if ten years ago you were instructed to interact with your clinician through a device you would be irritated and now there is a category of clients or patients who if they are not able to interact with their clinician through a device they are irritated. so this has really -- this is transformational and i know the chair and ranking member are

very supportive. i want to ask you another question. clearly your philosophy, i'm not sure if it's fair to call it federalism but you want to provide maximum flexibility to states in terms of interpreting aca and other statutes and in terms of configuring the healthcare system that makes most sense either through the state insurance commission or through the legislature so i want to ask you maybe a ticklish question, a tough one, which is it is one thing to provide flexibility if it is in the interests of your view of where healthcare should go. what if a state comes to you and says, we want to do a medicaid public option? what if a state comes to you and says, we want to do something that is left leaning, progressive leaning, more coverage, more government involvement? i am assuming because of my brief interactions with you and your reputation that you would provide the same flexibility as it relates to a progressive proposal that you would provide to anything that is designed to

in my view evade or undermine aca. >> i think you've seen that with our behaviors, for instance, our collaborative approach working with the state of maryland on their all payer program that they have had, which, you know, some would have a lot of concern depending on ideology, but we've tried to work with them to see if they -- it's a model of value-based payment that they are approaching and we've tried to be very collaborative in working with them. we also in our budget proposal have a proposal to congress that we would have -- we would cover up to five states the opportunity to negotiate directly drug pricing through their medicaid programs to test and see if that can deliver better results than the rebate program. we try to be open-minded. we have certain restraints around medicaid and medicare waiver of course, protecting the public fisc, budget neutrality requirements that depending on what one might want to do at a

state limit would be contrary to that and that might be an outer limit barrier. >> one final question. tom price said that repealing the individual mandate will harm the pool and likely have individuals younger -- you know this, you know the quote, it's adverse selection, it will drive costs up. do you agree with tom price? do you think he misspoke? >> i think he -- my understanding is that he backed away from that statement a little bit later but i will tell you my view on the individual mandate which is i really do not believe it will have a significant impact on our risk pool, the repeal of that. we already had 6.7 million americans playing $3.1 billion of taxes a year, 80% of them earning $50,000 or less because they can't afford this insurance, it doesn't work for them. i think that people were getting in that pool as i mentioned earlier to senator murphy, are people that were basically subsidizing access to. it's not the mandate that's gotten the merits that we're basically giving them insurance, that's why this err a in there. i don't see the premium effect -- >> it seems you are such a

person who relies on data and expertise in so many instances but you are disagreeing with the consensus among actuaries and healthcare experts of exactly what the individual mandate did, but my time has expired. >> senator moran. >> mr. secretary, thank you for being here. i don't know you as well as i'd like and i look forward to developing a strong relationship. there are so many things within your department that are so important to the citizens i represent and this may be me doing more talking than you and i apologize for that, but i want to highlight some things that in your budget request that are in my view worthy of my reaction. first of all, nih. the budget that is before us is a $6 billion reduction in nih funding. i would indicate to my colleagues and certainly to the ranking member and chairman of this committee that we ought to continue our efforts in finding ways to fund nih at increasing

rates and certainly without reductions. i think in a broader sense i think we as a congress for a long time have focused on who is going to pay for healthcare as compared to how can we make healthcare less expensive. the focus is how do we shift unaffordable healthcare to someone else who it's still unaffordable for. so it seems to me that the underlying cause of why healthcare is expensive is where we ought to focus and you are doing that and i appreciate that and nih in my view is one of those things not only does it improve people's quality of life and longevity, it's wonderful for families. if we can find the delay to onset of alzheimer's, if we can eliminate cancer, reduce diabetes, all those things have a tremendous cost consequence and we ought to be pursuing them. in regard to the cdc, i would advocate for continued funding of the global health fund.

one of the things that was said recently in the rescission discussion from omb was that ebola -- in a says they were saying ebola has been taken care of, no reports of ebola. there were two reports from congo shortly thereafter, but i also would say that regardless of reports of ebola, we need to continue to have the funding necessary for the infrastructure so that we don't start anew, we don't have the crisis we had when ebola arrived. for us this is not just a problem in africa or elsewhere in the world. the consequences of ebola and other highly contagious deadly diseases has a huge consequence upon americans and we saw that with ebola. so i would -- would highlight the importance of not eliminating the infrastructure that's in place to fight these highly dangerous and contagious diseases even though there may not be a report of that particular disease at the moment. so those two things i wanted to mention.

i walked in as senator lankford from oklahoma was talking about drug pricing, transparency, pbms. senator capito and i have long before supporters of legislation that requires transparency in the pbm world. i can tell you our legislation is not advanced very rapidly and i would look forward to hearing from you knowing from you how we can be assistance -- assistance to you and your department's effort, but this issue of rebates that's now front and center, i think maybe our conversation is better had once the announcement from the administration occurs as to what your plan, what your policies are going to be, but this, again, is an example of where -- if we can find ways to reduce unnecessary costs in healthcare, we can -- and the cost of healthcare, we can reduce the unnecessary costs of healthcare. so i applaud the department's efforts in regard to drug reform and particularly as it relates

to pbm transparency and the rebate issue. i'm encouraged. you and i visited on the phone i guess it's now last week. i would highlight for you once again the importance of the 340-b program. our hospitals from our largest and our most urban settings to our critical access hospitals, all of them are fragile. this is a funding source that helps the patient as well as the provider and in your alterations if there are any of 340-b, i guess we are now waiting on the courts to tell us some direction, provide us some direction, but i would highlight the importance of this 340-b program. there are 127 critical access -- i said that wrong, excuse me. there are 127 hospitals in kansas, 80 some of them are critical access hospitals, almost without exception it's hanging on by a thread and any alteration in their reimbursement rate means that there is going to be less access to healthcare in rural places in

particular, but in urban places as well, particularly the core center of urban centers. we have both in kansas, from johnson county is our suburbs of kansas city, one of the smallest towns in our state is johnson city, so from east to west this is a huge issue. it highlights for me -- i didn't realize when sequestration was passed that we had across the board cuts as they affected critical access hospitals. i thought sequestration would not apply to critical access hospitals. i didn't vote for sequestration, but as a bad policy it's the wrong way to approach the appropriations process, but i would have never thought that we would reduce across the board funding that affects critical access hospitals that are to be paid cost basis. this is this 2% across the board cut, in my view my colleagues and i need to make sure that this is not extended even further and look for opportunities for its demise. perhaps the only last point i would make is tribal labor

sovereignty, the words i use. your cms, center for medicare and medicaid services has taken upon themselves to declare native americans should be classified as a racial group rather than as citizens of a tribe. i think you're wrong. i think tribes should be treated and deserve the sovereignty that they are entitled to by our institution and long standing understanding that tribes are governmental not racial and i hope that cms will take a look at that issue once again on behalf of the tribes. thank you for answering all of my questions and at least i could say thank you for listening to my comments. >> if i might, mr. chairman, we did just earlier this week revise that guidance on cms. >> in regard to tribes? >> with regard to the community engagement and if you're talking about the community engagement participation states that have received those waivers and tribal connectivity to that, we have actually issued modified

guidance on that this week. >> i will take a look. >> senator baldwin. >> thank you, mr. chairman. welcome, secretary azar. i want to start about the issue of the high price of prescription drugs. so reports show last year that the pharmaceutical industry spent over $170 million in lobbying, deploying over 880 lobbyists to influence washington policymakers. this investment paid off for their ceos and shareholders. as first quarter earnings saw seven of the largest drug companies in aggregate receiving $12.1 billion in profits. this is since the beginning of this year. mean while, large drug

corporations received a tax cut from the republican tax bill and have spent a combined $50 billion on new stock buy-backs and enriched shareholders and executives while still continuing to increase prices on existing drugs. now, i understand that the president will be outlining a plan to address drug prices. we've been anticipating since his big announcement at the state of the union address and i am very interested in hearing what will be included. at your confirmation hearing before the help committee we had an exchange on this issue of the ever increasing price of particular prescription drugs and you blamed and i quote the system for the rising cost of prescription drugs, but you

never singled out the role that drug corporations play in this system. so i want to know whether the administration's plan is going to include actions that hold drug companies specifically accountable for their role in setting the price of drugs and increasing the price of drugs. yes or no? >> oh, yes, it will. all players will be impacted. as i said, it's a systemic issue which requires a multi-fact to recall solution and that's what the president will be rolling out tomorrow. >> one of the things i sent a letter with senator mccain to the president asking that he look at and support our fair drug pricing act. that requires basic transparency for drug companies when they plan to increase the price of their drugs. will a component of the president's plan be a call for

basic transparency for drug corporations, particularly but across that system generally? >> senator, i'm sure you will understand i'm not in a position to preempt the president of the united states tomorrow by saying what he will and won't announce. i apologize, but i'm happy to get back to you after that and discuss the issue of transparency, but in terms of any collars of the president's announcement, i'm afraid i do need to demur until tomorrow. my apologies, though. >> well, then, we will follow up on that. >> yes. >> i think for us as policymakers that's one of the most key aspects and certainly as we advocate on behalf of our constituents. i want to turn to the issue of the short-term health plans.

during the partisan repeal debate last year thousands and thousands of wisconsinites called on washington to protect their care. the administration in my opinion continues to undermine and sabotage the affordable care act and create more instability in the marketplace. now, there is what i view as a pretty radical proposal to expand the ability of companies to sell these skimpy short-term health plans that don't include basic consumer protections that are required, of course, in participation in the affordable care act, particularly things like preexisting condition coverage, and they exclude basic health benefits like maternity care or substance abuse

treatment. i think some of my colleagues know that when i was a child i was branded with the label preexisting condition after a childhood illness and my family couldn't find a health plan that would cover me. your plan would take us back to those days by allowing more junk plans and for longer periods of time. one of those plans sold in wisconsin today excludes coverage for preexisting conditions and refuses to cover non-emergency hospital services on the weekend. do you believe that insurance companies should be allowed to deny coverage or charge more for those with preexisting conditions? >> so these plans which are only a compensation for the failure of the affordable care act markets for those for whom it's not working, the 28 million people who do not have insurance because they've been shut out of that market, they cannot afford what's there, we're trying to bring back something that

president obama had which are these short term plans, people need to go in with their eyes open, they are not good for everybody, they will help in transitional cases, they may be available for those who cannot afford care. we're trying to make more options available there. the labor -- >> but you make them from three months to -- >> to 12, exactly what president obama had for the -- for up until the eve of the end of his presidency. 12 months is what's the proposal is to just restore what president obama had the entirety of his presidency. >> so this is right now three months. >> three months he changed in october of 2016, reverted it -- put it back to three rather than 12. it's an option, it's not meant to be the be all, end all, it's just -- we are trying to help those forgotten men and women who are sitting there with any options we can make available to them. >> why don't you add a requirement that those cover preexisting conditions? >> well, if we start making them the equivalent of the affordable care act, we will end up with the same pricing regimes, it would be replicating that.

we just want to make other options available for those who it makes sense and we're being very transparent. these will not make sense necessarily for all people, it's for folks for whom it makes sense we want to have options available. >> senator hyde-smith. >> senator, mr. chairman. thank you, senator azar for testifying today. i'm from brookhaven a small town in southwest mississippi to i'm really aware of the challenges that rural states presents in healthcare, but i was pleased to learn that the cms recently released the agency's very first rural health strategy intended to improve the quality of life for medicare benefits who live in rural areas so i thank you for working to ensure that the voices of rural patients and healthcare providers are heard and when your department considers payment policies and regulations, that also that consideration. secretary azar, can you discuss further how your physical year

2019 budget request will support health in rural america? >> thank you very much, senator, and it was a pleasure to meet you over the phone. thank you for that. first, the budget has $5.1 billion for community health centers and the community health centers serve 1 in 12 americans around the country, but in particular 86 million patients, one in six, living in rural areas. our bipartisan support for the community health center program is of course vital to healthcare in the rural communities. we also with the opioid epidemic we have added something very novel in here which is $150 million program for opioid treatment focused in rural areas and then of course we have the program that you mentioned that we've just laid out the cms rural health agenda and that's to -- we have programs there, for instance, that would allow medicare advantage programs to

deliver -- deliver telehealth services and other services in a rural area, more economically. i also want to look if you or others can identify where we have barriers in our payment regimes or regulations that impede alternative or innovative methods of care delivery in a rural setting. we know the issue in mississippi of rural hospitals suffering and closing. maybe traditional hospital models aren't the best way to deliver care or are economically feasible. are we getting in the way of the creativity of new models for delivering the kind of care that's needed in those communities. >> thank you. also rural america has 20% of the population and 9% of physicians. when i was in the mississippi legislature we worked to establish the mississippi rural physicians scholarship programs to help address the shortage of physicians in the rural areas in the state and it was a great benefit. we're still reaping those benefits today. how does your budget request

support physician workforce in rural places like mississippi? >> so what we've tried to do is prioritize the programs that we believe work the best, especially in getting providers to go to underserved areas and those are the scholarship and tuition reimbursement programs. as you look at, say, the hrsa budget our focus there is direct service, care delivery and then workforce training that is based on scholarship and tuition reimbursement. we just find that those programs deliver health professionals and they also have service obligations connected to them that help us get people into remote areas, underserved areas to be able to deliver as opposed to the programs we have that are, for instance, more subsidy payments to institutions, the individual targeted ones we think there is decades of evidence that show that those really do work and deliver and we want to focus in that space. >> thank you. >> thank you, senator hyde-smith. senator merkley. >> thank you very much. i'm going to follow up on that question about physician

shortage because it seems like we are all competing everywhere, our rural areas, our veterans administration as so many practitioners or baby boomers are retiring or so many of us are baby boomers and we need more healthcare. in that context i was somewhat surprised at the $48 million cut to graduate medical education and also on the nursing program, $145 million cut for nursing workforce development. all i'm hearing from my medical community is we need to train more doctors and more nurses and more pas and so why does it make sense to cut these programs? >> so with regard to the second program that you mentioned, the nursing program, that would -- that would get to the comment i was just making around the types of programs. the ones that support scholarship tuition reimbursement that are individually focused we think really can deliver. the institutional subs zags ones

in a scarce environment we think are less effective. in terms of graduate medical education what we've proposed is to combine the children's medical education, medicare and medicaid education into a single program funded by general revenue rather than focused on medicare and medicaid. we all benefit from the training of these physicians and nurses through the gme program and then allowing us to give us -- right now we are frozen in 1996. this would give us flexibility to target specialties as well as areas that most need the gme training. >> because i have so little time i'm going to cut you off there and just note that it appears even when those are added together there's less money for physician training and a lot less money for nurse training. while providing grants to go to rural areas is something that benefits my rural areas, it doesn't increase the overall numbers and that's the core problem. otherwise everyone is competing for a wool that's way too small.

let me turn to hepatitis b and c. i will keep this very short. there has been a big increase in hepatitis b and c. are you aware of it and will you support helping to take on this issue as we're here in this month when attention is supposed to be focused on it? >> absolutely. >> thank you. >> so much is connected to this opioid epidemic. >> it is very connected. absolutely. when you talked about the judge plans you said it's nice to provide as many options to people as possible, let them choose their option. why not let people choose medicare as an option? senator chris murphy and i and several of my colleagues have introduced a bill that says let people choose a medicare bill -- medicare policy if they want, a public option. we created a public option in oregon and you workers' comp that cut the cost in half. rhode island copied oregon's model with a public option, cut the cost of care in half. under your philosophy why not

allow a choose medicare option? >> the challenge with a medicare for all type approach is that we already have sustainability issues for our senior citizens in medicare -- >> okay. i'm going to cut you off there because this is a program separate from the existing pool for medicare. this would be medicare part e and it spends the money people spend on an exchange but let's them choose a better organized option that competes with the regular insurance options. if you're really for competition why not support a public option? i certainly think that the citizens would overwhelmingly and we see this in polling, overwhelmingly would like to see that they could have this choice on the exchange or enable their employers to be able to choose this. >> you are not going to be able to afford medicare without a subsidy and that would undermine the fiscal sustainability of medicare. we heavily subsidize medicare. >> you obviously haven't read the bill or you wouldn't say that because this is a stand-alone competition on a

level playing field parallel to the way we do it in oregon for workers' compensation. take a look at it, look for things that are market-based that actually work rather than undermining medicare for all citizens across this country as embedded in your current budget. and speaking of that, the medicaid block grant strategy that you've laid out based on graham cassidy, this would cut about $2500 peres peent in oregon. we have one of the lowest uninsured rates in the country and you just referred to your concern about those who don't have insurance. we have a very low rate because we've really actively worked on medicaid expansion. it's helped everyone in rural oregon and urban because the uncompensated care has dropped dramatically, meaning our clinics are thriving or at least doing far better than in states that didn't expand medicaid. i was just in a stated that three rural hospitals shut down because they didn't expand medicaid and they didn't have the finances to go forward. so why go to a program that will

produce the closing of rural clinics and rural hospitals desperately needed across america? >> so the affordable care act medicaid expansion as it is is an open-ended entitlement that is not going to be sustainable for us as taxpayers or for our government in the future. what we try to do is focus that on the individuals who now there is a significant disincentive towards the children, disabled and the aged in medicaid towards able-bodied adults through the expansion. it's basic math in terms of the incentive structure of how the affordable care act was structured and so we're trying to put medicaid on a more sustainable path forward for taxpayers and for the future of the program. >> sustainable means cutting healthcare for poor people and damaging rural america -- >> thank you, senator murky. senator rubio. >> thank you, mr. secretary for being here today. so there is a program that china is undertaken called made in china 2025, the plan is to

dominate the ten biggest technologies of the future, one of those ten is the pharmaceutical industry and in particular bio pharma. in fact, it was the second largest investment in china last year. and the way they do it is two-fold, one, they block off their own market to foreign competition and they do this in other industries, they're doing it now with bio pharma, but the other one is frankly they steal intellectual property and they do that through a number of methods, the foreign domestic partnerships they require, as a pharmaceutical industry you do business in china you have to partner with one of their clients. they have a track record of stealing for intellectual property. if you are not paying for the research, it's an incredible advantage. the other is they buy small companies including here domestically that have key research components of other industries, with he should anticipate the same in pharmaceuticals and the third frankly they just steal it. they break into a computer, through a cyber attack, this he

buy a business, or they go after the researchers. that's that's the part that i'm most concerned about. we spend a lot of money through nih to fund biomedical research and a lot of that is done through universities. i'm concerned about that because universities are soft targets, they're soft targets because, first, universities don't think this way, they operate in collaborative environments with other people and they are not used to sort of an adversarial setup that this proposes, but the other is i wonder whether they have the systems set up to protect themselves for intellectual property theft and that can be ranging from cyber all the way to actually being able to identify individuals and partners they're working with who ultimately are really just transferring intellectual property back to a chinese company or the chinese government to give them a competitive advantage. i would just say that if their growth in this field and advances were being driven by greater -- better innovation, more investment and all these sorts of things, then it would

be on us to become more innovative and invest more, but when a significant part of their advances on technology in general and biomedicine in particular is driven by intellectual property theft, well, we've got deep concerns and i also believe that this has significant national security implications for our country. i challenge people to think for a moment what the world would look like if the latest greatest cures for diseases including -- or potentially things like alzheimer's that have have a very significant impact on our budgets for years to come were controlled by china, the amount of leverage that that would provide them geopolitically and the like. so i was curious whether anyone at the agency is thinking about this, thinking about how to protect our research knowing that this industry is a target of a nation with a long track record of stealing intellectual property. >> senator, thank you very much for raising and highlighting what is a very important issue,

it is one that is on our radar, one we are working on and i would be happy to work with you off-line also in appropriate settings to discuss this. i think you have hit on a really quite important issue. >> all right. the second question is more local and it has to do with preparedness. during the 2017 hurricane season my office at one point became in many ways a triage center, largely centered on getting federal agencies to communicate with each other and states. this is particularly problematic in puerto rico where there were delays in getting supplies and hhs medical teams to the island and i want to say there were multiple occasions in which fema on the department of defense caused delays and being able to get hhs supplies to puerto rico. fema took days to approve flights for hhs medical teams and some medical supplies. the dod took a week to respond

to initial medical requests to puerto rico. have we learned any lessons from puerto rico from the hurricanes in 2017, because i think this has applicability not just we're entering hurricane season now, but i think this has applicability for natural disasters in the future or quite frankly biological attacks or any other sort of mass public health threat we might face. >> again, thank you for raising what is an issue very much on my radar. we actually just had a session with dod and other agents -- interagency partners on lessons learned from the last season preparing for this with a focus in particular on transportation resources and our ability to deploy because of course we're often dependent on others for transport and so there is a major focus on lessons learned from the unprecedented cycle of hurricanes that really taxed of course our system and i'm hopeful that we have systems worked out better in connectivity even better to make sure we serve our people well.

>> senator shaheen. thank you, senator rubio. >> thank you, mr. chairman. mr. secretary, thank you for taking time to speak with me yesterday. i appreciated the call and the conversation and as told you, one of the biggest challenges we are grappling with in new hampshire is the opioid epidemic and how to respond to that. and i have been very concerned about making sure that those small states like new hampshire, west virginia, are able to get help because of the overdose rate, not just based on our population but because of the high overdose death rate, new hampshire ranks third in the country right now, first when it comes to fentanyl overdoses, that we have additional impacts that are not felt in some of the bigger states.

so i hope you will commit to working with me to ensure that those states that are hardest hit by the epidemic, because of not just in terms of population, but based on overdose death rate, will get some additional assistance to help us. >> thank you for your leadership and the committee's work on this, because it has been a concern of ours. we've heard that, and in the coming grant cycle, coming out of the omnibus, not only did the congress give us a 15% i believe set aside for the hardest hit state, but in addition, has given us the flexibility which we intend to use on the remainder of our grant programs to target those based on the burden of this crisis. >> do you have any sense of when the decision will be made about that $142 million, which is the set aside? >> i know generally the next round is expected in september to get out in september. i don't know if on the set aside

amount that's on a different timeline. i would be happy to get back to you on that. >> thank you. we also talked about drug pricing, which is a huge issue. it's not just an issue for families who can't afford drugs, particularly senior citizens, but in terms of driving up the cost of health care. one of the issues i'm most concerned about having with -- having attended the aging committee hearing on the cost of insulin is what's happening with the price of insulin. i've got -- i don't know if you can see this, you can probably just see the trajectory of pricing, but this is insulin prices, this line. and we should have had it blown up. mr. chairman can i ask that this be entered into the record? what it shows is that these insulin prices started going up dramatically in 2003 after we passed medicare part d. so clearly there is -- i believe there's a correlation between what's happening with the cost of insulin, and i'm sure other

drug prices, and our failure to negotiate with pharmaceutical companies. but can you talk about what you can do at hhs to help address the cost of insulin, which is not an option for people who need it, it's life or death. >> so i would like to, if i could, speak generally about what we need to do around the drug issue first in the budget proposal that we have in this fy-19 budget, we have a five-part plan that we would propose to congress around restructuring many elements of the successful part d drug program, but taking learnings from the last 15 years, you have highlighted one, which is the incentives in the system towards higher list price, given that we as taxpayers sit at what's called the catastrophic period. j there, if the drug can march on through there and get to the catastrophic period, we the taxpayers bear 80% of that cost, and the drug plan only bears 15% of that.k&o(

we've proposed to congress to flip that around to give those drug plans more of an incentive to cram down those list prices. so that's an important part of what we're driving towards. of course, tomorrow the president will lay out even more, focused on these issues of list prices that you have raised. >> thank you. i appreciate that. and look forward to hearing the announcement. hhs recently issued a funding opportunity announcement for title 10 family planning grant dollars that really alters the focus from selection of grantees who have focused on contraceptive care toward abstinence only approaches. we have the lowest teen pregnancy ever in this country's history right now. most of the data that i've seen indicates that's because we have focused on contraceptive care, on access to reproductive health care for not just young people but for everyone. so i don't understand why we are fooling around with something

that's been working to address the issue of unplanned pregnancy, particularly teen pregnancy, to focus on an approach that all of the data that i've seen shows doesn't work. >> so senator, in the funding announcement that we did there, the intention was to comply with the statutes, and mandate that we have a broad range of planning services. so not just contraception, but natural family planning, which has called out expressly in the statute. not meant to favor one over the other, but streamline our grant making processes to make it more efficient. so the intention there is a broad range of providers, as well as receivable the full range of services that title 10 asks us to provide. >> thank you. i have a follow up, but i'll do that for the record. thank you, mr. chairman. >> thank you, senator sheen. go ahead and ask your question right now. >> well, again, do i

misunderstand when i look at this funding opportunity announcement and, as i said, my interpretation is that it focuses on abstinence only approaches. >> it offers natural family planning as one part of comprehensive or a broad range of family planning, but doesn't set aside, i don't believe does any set aside or preference one over the other rather has the full range of availability. if a provider wishes to provide in the one category they can, but there's nothing that says one is disadvantaged by providing in the nonnatural family planning, the contraceptive type arena. so it's meant to encourage the broad range, which is exactly the language of title 10, the broad range of family planning services. so i believe it's meant to be

eccumentical a aa aal agnostic. >> i would suggest i believe our communication has gotten better under your leadership. i think it can always be better and hopefully we continue to do that. on the unaccompanied children issue, i think we are -- i'm not comfortable with what we know from the department, so if you can help us with that so we can have a little more ability to plan that. we'll be asking a questionable the recovery audits. i know the u.s. district court recently ruled that hhs needs to pay the people that have a back load of claims by 2021, particularly for small hospitals and rural hospitals generally

that can't afford to have a staff of auditors and lawyers to fight these -- the longer they stay in this line and don't get their issue decided, the more challenging it is for them. your budget request of an additional $70 million for this purpose, i guess one of the questions is do you think that meets the court deadline that by the end of 2020, everybody currently in this long list of recovery audits is going to have their situation dealt with. also, on the mental health side, i would hope that you continue to look at excellence in mental health, and determine how that can become if the pilot produces what i believe it will, how that can become part of our future policy and our future funding

for treating mental health like all other menlt mental health. we have a new investment of $100 million to provide treatment for americans that suffer on a clinic and community basis where they can ask for their -- for part of that $100 million. that's a new program. we'll be asking to see if that program is working. on another topic of transferring things to nih, i would just say, one of us is not understanding the discussion here. we have the same request to transfer a bunch of things like national institute of occupational safety and health, the national institute of independent living and rehabilitation research to nih. it's been the view of the committee that they have enough to do, and that's a priority, and those things bog them down. we probably need to be sure we

understand your argument on this. it's the second time you've made it. if you really want it, let's see that we give you a chance to make that case, and so for me, the committee will get those and other questions. senator murray? >> thank you, mr. chairman. let me just make comments on two things and i have one more question. on the teen pregnancy prevention program, i was actually out in washington state a couple of weeks ago and spoke to the director of the king county public health department. they operate a program called flash. it's a family life and sexual life health program. it was one of the previous tpp grantees whose funding was terminated by your office in the middle of their five-year grant. my understanding is widespread use of the flash curriculum has had great results. the teen birthrate fell by 60% since 2008. and despite that, your office

terminated it. i just want you to know you're effectively throwing away really valuable data that these grantees have collected over the past three years that can really help us inform pregnancy prevention. and i want you to know too that the bipartisan commission on evidence based policymaking, which was established by myself and paul ryan highlighted the tpp program, teen pregnancy program, as an example of a federal program developing rigorous portfolios of evidence. i know this is the subject of litigation right now in terms of our grantee, but i will continue to follow this and i'm really concerned where it's going, with the changes you proposed. the other issue i want to highlight is maternal mortality. i'm really troubled that greater proportions of women in this country are now dying of pregnancy related complications,

more than any other developed country in the world. and we are -- the u.s. is the only country where the rate of these deaths have been rising. that is troubling to me. it's just so critical that we improve systems of maternity care, including clinical and public health systems. we have to work on eliminating this preventable maternal mortality that we're seeing across the country. ly be talking with you about that. i do have one final question, and that is on the research. the last time we spoke, we talked about the centers for disease control and prevention reengaging in gun violence research. i have spoken with dr. redfield and the cdc director about that. since then, kaiser permanente announced it would invest $2 million to start working on this issue. along with a group of seven bipartisan governors who launched a quick consortium to

study it. so it's time for cdc to do the same. and dr. redfield says science based data, the cdc is the best science based data driven agency in the world. we should be using them. so i wanted to ask you, do you intend to -- actually, can you reprogram or transfer today to begin this work? >> i don't know about that. but i have spoken with dr. redfield to make clear our understanding of the dicky amendment, which is we're not prevented using appropriated funds if we were appropriated funds for gun violence research. we do that at nih today. we have programs on violence and gun violence research at nih, as you know, because you appropriate the money. nih is much more open for peer review funding of --

>> my question is -- >> the cdc is not that way. we're very directed in where the money goes there. >> but can't you reprogram -- if this is a priority for you, i believe that you can reprogram or transfer funds directly for that reason. >> i would have to look into that. >> if you could do that and get back to me. >> will do. >> or are you intending to include gun violence research funding in your next budget mission? >> that would be a matter between the department and omb. i couldn't comment on where we will be as an administration. >> would you will willing to ask about that? >> i cannot reveal my deliberative work with the -- >> would you please. >> i appreciate your concern there. >> thank you. >> thank you, senator murray. the record -- and thank you for being here. the record will stay hope for one week for additional questions, and the subcommittee will stand in recess.

coming up later this afternoon here on c-span3, starbucks executive chair howard schultz speaking in washington about his vision of corporation's responsibilities to society. which he says include improving education, employment, health care and quality of life. his remarks at 1:30 eastern right here on c-span3. and you can listen with the free c-span radio app. and coming up this evening on c-span, president trump and vice president mike pence in elkhart, indiana, campaigning for

republican senate candidate mike braun. he's challenging incumbent democratic senator joe donally. the rally is set for 7:00 p.m. eastern. live coverage on c-span, and the free c-span radio app. >> sunday morning on 1968, america in turmoil, we look at the cold war as the backdrop for the events of 1968, including the vietnam war, the presidential campaign and the space race. joining us to talk about that turbulent time are elizabeth cobbs, documentary filmmaker. and mark cramer, program director of the project on cold war studies at harvard university. watch "1968, america in turmoil," live sunday at 8:30 a.m. eastern on c-span's kra journal and on american history tv on c-span3.

>> now a conversation on protecting u.s. election systems from hacking. we'll hear from a computer science professor at the university of california at irvine. >> okay. thanks and welcome, everyone, to this panel. i'm going to begin by introducing each of the three panelists and we'll have short presentations from the panelists and then a discussion and we'll open it up for questions from the audience. so directly to my right is alex halderman, professor of computer science and engineering at the university of michigan. and director of the university of michigan's center for computer security and society. his research focuses on computer security and privacy with an emphasis on problems that broadly impact society and public policy. so this includes electronic voting, computer forensics, ethics and cyber crime. he's alsoer